NURS 6512 Week 8 Discussion: Episodic/Focused SOAP Note Template
NURS 6512 Week 8 Discussion: Episodic/Focused SOAP Note Template
Episodic/Focused SOAP Note Template
Patient Information:
[elementor-template id="165244"]Age: 42yo Sex: Male
S.
CC: “Lower back pain that sometimes spreads to the left leg.”
HPI:
Location: Lower back and sometimes the left leg.
Onset: One month ago.
Character: Not stated.
Associated signs and symptoms: Not included.
Timing: Not indicated.
Exacerbating/ relieving factors: No exacerbating or relieving factors were mentioned.
Severity: Severity not specified.
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Current Medications: No current medication.
Allergies: No allergies.
PMHx: Immunized against COVID-19 in 2020.
Soc Hx: Married and lives with his wife and children. He reports taking 5 beers weekly. Denies using tobacco or other illegal products.
Fam Hx: Not included.
ROS:
GENERAL: Denies weight gain or muscle weakness.
HEENT: Denies headache, visual loss, hearing loss, sneezing, runny nose, or sore throat.
SKIN: Denies skin pigmentation.
CARDIOVASCULAR: Denies palpitation.
RESPIRATORY: Denies shortness of breath.
GASTROINTESTINAL: Denies constipation or diarrhea.
GENITOURINARY: Denies blood in the urine.
NEUROLOGICAL: Denies numbness in the extremities.
MUSCULOSKELETAL: Reports lower back pain. The pain sometimes spreads to the thigh.
HEMATOLOGIC: Denies bruising.
LYMPHATICS: Denies enlarged lymph nodes.
PSYCHIATRIC: Denies anxiety or depression history.
ENDOCRINOLOGIC: Denies excessive sweating.
ALLERGIES: Denies rhinitis.
O.
Physical Examination
VS: BP 187/103; T 98; P 96; R 18; 02 97% Wt 275lbs; Ht 72”
General: The client is a 42 years-old male who is smartly dressed. During the interview, the client is attentive and responded to most interview questions correctly. His self-reported mood is “fantastic.” The client does not seem to be in acute distress and is future-oriented.
HEENT: Clean cut and well maintained black hair. Equally round eyes that are reactive to light. Bilateral external auditory canals. No ulcers to gums. No erythema to the throat.
CV: Normal S1 and S2.
Lungs: No signs of respiratory difficulty.
ABD: Non-tender, large, and soft.
GU: N/A
PV: No edema to the lower extremity.
MSK: Ability to bend and extend the back detected.
Neuro: Flexible movement with no difficulty detected in all extremities.
Psych: Good mood noted. The client does not seem to be anxious.
A.
Differential Diagnosis
Below is a list of the client’s differential diagnoses based on medical history and physical examination results. Diagnoses are listed from the most likely to least likely condition.
- Sacroiliitis – Pertinent diagnosis
- Cervical Radiculopathy
- Osteoporosis
Sacroiliitis
Sacroiliitis qualifies as the pertinent diagnosis for this client. This disorder is mainly characterized by pain in the low back pain that might spread to the leg, hip, or buttock (Baronio et al., 2020). This client reported pain in the lower back that might spread to the leg; hence qualifying for this primary diagnosis.
Cervical r Radiculopathy
This is the second potential diagnosis for this client. This disorder is characterized by a sharp pain in various body parts, including the back, legs, arms, or shoulders, which worsens when performing certain activities, including sneezing or coughing (Kang et al., 2020). The client might have this condition since he reported pain in the lower pain that occasionally spreads to the left leg. However, radiculopathy since the client did not report an increase in pain with activity, which is a major property of pain related to this condition.
Osteoporosis
The client also qualifies for this diagnosis. Osteoporosis is characterized by various symptoms, including back pain, resulting from a fractured or collapsed vertebra; a stooped posture; loss of height over time; and easily breakable bone (Pouresmaeili et al., 2018). The client might have this condition since he reported lower back pain. However, this condition is ruled out due to the absence of significant symptoms, including a stooped posture; loss of height over time; and easily breakable bone.
References
Baronio, M., Sadia, H., Paolacci, S., Prestamburgo, D., Miotti, D., Guardamagna, V. A., … & Bertelli, M. (2020). Etiopathogenesis of sacroiliitis: implications for assessment and management. The Korean Journal of Pain, 33(4), 294-304.
Kang, K. C., Lee, H. S., & Lee, J. H. (2020). Cervical radiculopathy focus on characteristics and differential diagnosis. Asian Spine Journal, 14(6), 921. Doi: 10.31616/asj.2020.0647
Pouresmaeili, F., Kamalidehghan, B., Kamarehei, M., & Goh, Y. M. (2018). A comprehensive overview of osteoporosis and its risk factors. Therapeutics and clinical risk management, 14, 2029. Doi: 10.2147/TCRM.S138000.
ORDER A CUSTOMIZED, PLAGIARISM-FREENURS 6512 Week 8 Discussion: Episodic/Focused SOAP Note Template HERE
To prepare:
Your Discussion post should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style Discussion posting format. Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources for guidance. Remember that all Episodic/Focused SOAP notes have specific data included in every patient case.
By Day 3 of Week 8
Post an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in the Week 5 resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.
Discussion: Assessing Musculoskeletal Pain
Photo Credit: Getty Images/Fotosearch RF
The body is constantly sending signals about its health. One of the most easily recognized signals is pain. Musculoskeletal conditions comprise one of the leading causes of severe long-term pain in patients. The musculoskeletal system is an elaborate system of interconnected levers that provides the body with support and mobility. Because of the interconnectedness of the musculoskeletal system, identifying the causes of pain can be challenging. Accurately interpreting the cause of musculoskeletal pain requires an assessment process informed by patient history and physical exams.
In this Discussion, you will consider case studies that describe abnormal findings in patients seen in a clinical setting.
To prepare:
By Day 1 of this week, you will be assigned to one of the following specific case studies for this Discussion. Please see the “Course Announcements” section of the classroom for your assignment from your Instructor.
Your Discussion post should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style Discussion posting format. Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources for guidance. Remember that all Episodic/Focused SOAP notes have specific data included in every patient case.
Review the following case studies:
Case 1: Back Pain
Photo Credit: University of Virginia. (n.d.). Lumbar Spine Anatomy [Photograph]. Retrieved from http://www.med-ed.virginia.edu/courses/rad/ext/5lumbar/01anatomy.html. Used with permission of University of Virginia.
A 42-year-old male reports pain in his lower back for the past month. The pain sometimes radiates to his left leg. In determining the cause of the back pain, based on your knowledge of anatomy, what nerve roots might be involved? How would you test for each of them? What other symptoms need to be explored? What are your differential diagnoses for acute low back pain? Consider the possible origins using the Agency for Healthcare Research and Quality (AHRQ) guidelines as a framework. What physical examination will you perform? What special maneuvers will you perform?
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